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Authors

Theerachai Apivatthakakul, Jong-Keon Oh

Executive Editor

Michael Baumgaertner

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Percutaneous reduction techniques (trochanteric fractures)

1. General considerations

It is important to assess the reduction quality correctly and repeatedly (to recognize and correct intraoperative redisplacement).

2. Reduction techniques

Reduction of flexion deformity

Create a stab incision and insert an elevator. Position the tip on the anterior beak of the proximal fragment.

While supporting the femoral shaft by an assistant, push the proximal fragment with the elevator to reduce it anatomically.

A crutch or other support underneath the femoral shaft may prevent it from sagging down during the reduction step.

Reduction of a flexion deformity of a trochanteric fracture with an elevator and a support underneath the femoral shaft

Axial view of an anterior beak of the proximal fragment

This displacement was reduced by pressing down the anterior beak with an elevator. The shaft needs to be supported.

Axial view of a trochanteric fracture with the anterior beak of the proximal fragment reduced with an elevator

Reduction of valgus deformity with medial gap

Insert a bone hook along the anterior cortex and place its tip on the medial cortex of the proximal fragment to pull it laterally.

Intraoperative view of a trochanteric fracture reduced and held with a bone hook

Leverage technique for reduction of step-off/neck-down deformity

Hook leverage technique

Insert a hook through the main incision (here shown for the nailing) along the anterior cortex.

Introduce the tip of the hook between the proximal and distal fragment into the fracture site.

Hook leverage technique for a reduction of a step-off or neck-down deformity of a trochanteric fracture

Engage the hook with the proximal fragment and turn the hook around its longitudinal axis.

Hook leverage technique for a reduction of a step-off or neck-down deformity of a trochanteric fracture

Axial view of the leverage maneuver 

Hook leverage technique for a reduction of a step-off or neck-down deformity of a trochanteric fracture

This maneuver disimpacts the proximal fragment and helps to align the cortices (Kim et al 2014).

AP view of the final hook position

Hook leverage technique for a reduction of a step-off or neck-down deformity of a trochanteric fracture
Anterior leverage technique

If using an elevator, introduce it through an anterior skin incision on the level of the fracture gap.

Insert the tip of the elevator into the fracture gap and lever it up.

Anterior leverage technique using an elevator

Lateral view showing the elevator introduced 

Anterior leverage technique using an elevator

Same lateral view after levering the elevator distally to reduce the fracture

Anterior leverage technique using an elevator

Low intertrochanteric fracture

A low intertrochanteric fracture behaves like a subtrochanteric fracture. The lesser trochanter is part of the proximal fragment.

Such a fracture may be reduced as follows (Park et al 2010): Insert a Kelly clamp through a posterolateral stab incision. Place its tip on the anterior cortex of the intertrochanteric area. By lifting the Kelly clamp, the soft tissues are rotated internally, and the flexed proximal fragment is pushed down.

Kelly-clamp reduction of a low intertrochanteric fracture

3. Maintaining reduction

For preliminary fixation, place a K-wire through the neck into the femoral head. The paths for planned implants should be avoided.

For nailing, this K-wire needs to be anterior to the nail path and superior to the blade path.

Insertion of a K-wire for preliminary stabilization of the reduced trochanteric fracture with a planned nail fixation

For application of a DHS, this K-wire should be in line with the head-neck axis in the axial view and superior and parallel to the planned lag screw in the AP view. It may also serve later as an antirotation wire.

Insertion of a K-wire for preliminary stabilization of the reduced trochanteric fracture with a planned sliding hip screw fixation

4. Assessment of reduction quality

Assess the reduction quality after provisional fixation in AP, lateral, and axial views.

Repeat the assessment of reduction after each step of implant positioning to recognize any intraoperative loss of reduction.

5. Case

Reverse oblique intertrochanteric fracture

This case shows an intertrochanteric fracture.

It was chosen to stabilize the fracture with a short nail.

Intraoperative views of an intertrochanteric fracture

A first reduction attempt with a trochanteric joystick and two Hohmann retractors has been made.

Attempt to reduce an intertrochanteric fracture with a trochanteric joystick and two Hohmann retractors

These lateral image intensifier views show the reduction of the translational displacement.

Lateral views of an intertrochanteric fracture reduction with a trochanteric joystick and two Hohmann retractors

In the AP view, there was still displacement visible, which required further reduction.

AP view of an intertrochanteric fracture reduction with a trochanteric joystick and two Hohmann retractors

In these image intensifier views, multiple reduction instruments applied percutaneously can be seen:

  • Joystick technique
  • Controlling the flexion deformity with a Hohmann retractor
  • Bone hook around the femoral shaft to counteract the manipulation at the trochanter
AP view of an intertrochanteric fracture reduction with a trochanteric joystick, a Hohmann retractor, and a bone hook

Besides these instruments, the guide wire for nail insertion is also visible, as well as a guide wire from a first attempt (in the axial view).

Lateral view of an intertrochanteric fracture reduction with a trochanteric joystick, a Hohmann retractor, and a bone hook

Final AP and lateral views with the inserted nail 

AP and lateral view of an intertrochanteric fracture fixed with a short nail
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